O'Neill Institute | January 24, 2024
Introduction
Last September the United Nations (UN) convened a high-level meeting dedicated to universal health coverage (UHC). The meeting was seen as a “historic opportunity” to adopt action-oriented commitments and “accelerate progress towards the achievement of universal health coverage by 2030.” Many stakeholders had hoped for Member States to adopt new commitments expanding upon the political declaration on universal health coverage previously agreed in 2019 and various other UN resolutions. Following several months of negotiations, UN Member States adopted the political declaration on universal health coverage during the high-level meeting.
This analysis examines the political commitments adopted by UN Member States. Leveraging a compilation of international sources in the HIV Language Compendium, this analysis compares the commitments agreed this year with language already reflected in other UN resolutions. Contrary to the expectations leading to this process, the political declaration on universal health coverage largely missed the opportunity to expand upon previous international commitments.
While recommitting to work towards achieving universal health coverage, the resolution adopted by UN Member States this year missed the opportunity to explicitly recognize the need to protect vulnerable populations including transgender people, men who have sex with men, sex workers, people who use drugs, and people in prisons. Despite calls to advance “comprehensive approaches and integrated service delivery,” the HIV-specific commitments adopted this year are weaker than those reflected in other declarations. Other international resolutions have also adopted stronger commitments specifically related to gender, digital health, and community leadership. Access to affordable health technologies will be critical to ensure the sustainability of programs aiming to achieve universal health coverage. Yet the commitments made this year on access to health technologies are generally nonbinding and weaker than in other UN resolutions.
Key and vulnerable populations
Criminalized, discriminated, and stigmatized people tend to avoid health prevention and treatment programs. This undermines the effectiveness of health programs and further deepens the vulnerability of the criminalized, discriminated, and stigmatized populations. Transgender people, men who have sex with men, sex workers, people who use drugs, and people in prisons tend to be among the key and vulnerable populations often subject to criminalization, discrimination, and stigmatization. Numerous international sources have therefore explicitly recognized the rights and vulnerabilities of these populations in accessing healthcare. States have recognized the rights of these specific vulnerable populations for instance in the 2021 political declaration on HIV and in the 2018 political declaration on the fight against tuberculosis.
Paragraph 48 of the 2023 political declaration on UHC called for ensuring that no one is “left behind,” recognizing the need to protect vulnerable populations and people in vulnerable situations. This includes women, children, youth, persons with disabilities, people living with HIV, older persons, people of African descent, indigenous peoples, refugees, internally displaced persons and migrants, and those living in poverty and extreme poverty in both urban and rural areas, people living in slums, informal settlements or inadequate housing. Yet paragraph 48 of the political declaration failed to go further by explicitly recognizing the need to protect transgender people, men who have sex with men, sex workers, people who use drugs, and people in prisons, in line with other international resolutions. The failure to explicitly recognize the need to protect these populations in the 2023 UHC political declaration was a missed opportunity.
Needs of people living with HIV
People living with HIV are one of the key and vulnerable populations requiring special emphasis in policies towards universal health coverage. Recognizing this, previous UN resolutions have reflected political commitments to accelerate “integration of HIV services into universal health coverage.” These commitments require investments in “robust, resilient, equitable and publicly funded systems for health and social protection systems.” These investments should seek to provide 90% of the population living with, at risk, and affected by HIV with “people-centered and context-specific integrated services for HIV” and other health services by 2025. Countries have also committed to ensuring that 95% of people living with, at risk of and affected by HIV are protected against health emergencies, that 90% of people in humanitarian settings have access to integrated HIV services and that 95% of people in humanitarian settings at risk of HIV use appropriate, prioritized, people-centered and effective combination prevention options.”
Paragraph 55 of the 2023 political declaration on UHC called for strengthening efforts to address the specific physical and mental health needs of all people as part of universal health coverage. This paragraph also called for “advancing comprehensive approaches and integrated service delivery,” including for HIV. Despite calls to advance “comprehensive approaches and integrated service delivery,” the 2023 political declaration on UHC lacks concrete and programmatic commitments specific to HIV such as those previously reflected in other UN resolutions.
Gender and women rights
Paragraph 61 of the 2023 political declaration on UHC called for “mainstream[ing] a gender perspective on a systems-wide basis when designing, implementing and monitoring health policies.” According to the 2023 political declaration, this perspective should take into account “the human rights and specific needs of all women and girls, with a view to achieving gender equality and the empowerment of women and girls.” Paragraph 61 of the 2023 political declaration on UHC also called for “ensuring women’s effective participation and leadership in health policies and health systems delivery.” Paragraph 95 of the political declaration on UHC called for addressing “inequalities, including the gender pay gap, by appropriately remunerating health workers and care workers in the health sector, including community health workers.”
While important, these commitments are largely based on language that had already been adopted in the 2019 political declaration on UHC. Several UN resolutions have made stronger commitments on issues generally related to gender equality with relevance to universal health coverage. By mostly reflecting previous commitments, the 2023 political declaration on UHC failed to take advantage of an opportunity to make stronger commitments on gender equality.
Human rights in digital health environments
All human rights that people have offline must be protected online. This was clearly stated in the 2022 UN General Assembly (UNGA) resolution on the right to privacy in the digital age. Fulfilling this principle requires protecting privacy when using digital technologies in the implementation of all health programs, including prevention, treatment, and during emergencies. Yet other human rights can also be threatened in the implementation of digital health technologies. For instance, the use of artificial intelligence without proper safeguards can reinforce discriminatory practices, including structural inequalities. Therefore, States must commit to protecting all human rights and principles in the implementation of digital health technologies, including non-discrimination.
Paragraph 80 of the 2023 UHC political declaration recognized “the need to protect data and privacy” in the implementation of digital health technologies. This commitment tracks language already reflected in paragraph 66 of the 2019 UHC political declaration. States had an important opportunity to expand their commitments on digital health and UHC, for instance by explicitly recognizing the need for placing safeguards to protect everyone against discrimination in the deployment of artificial intelligence technologies. Yet they missed the opportunity.
Table 1. UN commitments on protecting human rights in digital health environments
| 2019 UHC declaration | 2022 Resolution on the right to privacy in the digital age | 2023 UHC declaration |
| Recognized the need to protect privacy in digital environments | All rights and principles should be protected online, including non-discrimination. | Tracked the 2019 declaration recognizing the need to protect privacy |
Community leadership
Placing communities at the center of healthcare planning, design, delivery and monitoring is critical to ensure that these programs are equitable, effective, and sustainable. Community leadership further encourages the co-creation of innovative programs tailored towards addressing the needs of key populations. These positive effects have been evidenced in research showing that community-led initiatives are central to equitable pandemic preparedness and responses. Research has also demonstrated that community leadership is more effective in settings where laws criminalize same-gender sex, sex work, or drug use. Community leadership at all stages of decision-making must therefore be a component of efforts to achieve universal health coverage.
The 2023 UHC political declaration includes statements recognizing the importance of “community-based” services, as reflected for instance in paragraph 32. Paragraph 33 of the 2023 UHC political declaration further acknowledges “the potential role of community-led initiatives and community engagement in building trust in health systems.” Nevertheless, the 2023 UHC political declaration lacks ambitious, concrete, and programmatic commitments to support and place communities at the center of healthcare planning, design, delivery, and monitoring. Programs attempting to achieve universal health coverage will be less equitable, less effective, and less sustainable without placing community leadership at the center of these efforts.
Patient empowerment and self-care promotion
Self-care is one of the most important and promising complementary medicine services. “The provider-to-client model that is at the heart of health systems must be complemented with a self-care model through which people are enabled to make active, informed health decisions to promote health, prevent disease, maintain health and cope with illness and disability with or without the support of a health worker.” Self-care interventions can improve equitable access to health, alleviate pressure on health systems, and reduce financial costs. Individuals choose self-care interventions given their convenience, confidentiality, and cost. People can also choose self-care if they anticipate that they may face stigma and discrimination. Self-care interventions grounded in human rights further promote autonomy through informed decision-making, active and informed participation of individuals, privacy and confidentiality, and increased availability and
accessibility to complement facility-based care. Given these benefits, self-care interventions can “accelerate attainment of universal health coverage.”[1]
Early drafts of the 2023 UHC political declaration made references to the need to promote self-care. Operative paragraph 34 of the revised draft circulated on 23 June 2023 acknowledged the role of digital health tools in promoting self-care “as well as empowering patients by strengthening patient involvement in clinical decision-making.” While the final political declaration also acknowledged the role of digital health tools in “empowering patients by strengthening patient involvement in clinical decision-making,” explicit references to self-care were dropped. Failure to explicitly recognize its importance was another missed opportunity.
Access to health technologies
Alternative research and development models
Ensuring the sustainability of universal health coverage largely depends on costs. A key driver of costs is the price of pharmaceutical products and other health technologies. Therefore, efforts to achieve universal health coverage should include measures to address these high prices.
Pharmaceutical innovation can be incentivized throughout models that delink research and development costs from prices. Given the potential for promoting access to health technologies, the concept of delinkage has gained increasing interest among national governments in recent years. At the international level, States have made commitments to “support” and “collaborate” on delinkage incentive models. This was reflected in the 2019 UHC political declaration, where States committed to “continue to support” incentive mechanisms “that separate the cost of investment in research and development from the price and volume of sales, facilitate equitable and affordable access to new tools and other results to be gained through research and development.” Other agreements with commitments on delinkage include the 2021 political declaration on HIV and AIDS, the 2018 political declaration on the fight against TB, the 2022 UN Human Rights Council (HRC) Resolution on access to medicines, vaccines and other health products, the 2021 HRC resolution on ensuring equitable, affordable, timely and universal access for all to vaccines in response to COVID-19, and the 2019 HRC resolution on access to medicines and vaccines.
Building upon the 2019 UHC political declaration and other international agreements, States could have expanded their commitments around delinkage at UNGA this year. Like in other precedents, States should have agreed to “collaborate” on delinkage initiatives and indicate what concrete steps would be followed to fulfill that commitment. Yet on delinkage States mostly reflected the language that had already been adopted in the 2019 UHC declaration.
Table 2. UN commitments on alternative research and development (R&D) models
| 2019 Declaration | 2023 Declaration | Other agreements |
| Committed to “continue to support” incentive mechanisms that separate R&D costs from prices | Tracked the 2019 declaration commitment to “continue to support” incentive mechanisms that separate R&D costs from prices | In addition to “support”, other international precedents have called for collaboration on incentive mechanisms that separate R&D costs from prices (e.g., A/HRC/RES/50/13) |
Technology transfer
Increasing competition is critical to curb high prices and ensure equitable access to health technologies globally. Ensuring global equitable and affordable access to health technologies is essential for the sustainability of programs that seek universal coverage. In contrast, failure to facilitate or mandate technology transfer creates legal and economic barriers to competition, allowing product originators to set excessive prices. Lack of technology transfer also restricts the supply of health products, often leading to their inequitable global distribution including during emergencies. This undermines the sustainability of efforts to achieve universal health coverage.
Contrary to the 2019 UHC political declaration, this year UN Member States included some references acknowledging the need for technology transfer. These references are in paragraph 74 and 106 of the 2023 UHC political declaration. Paragraphs 74 and 106 represent a slight improvement from the 2019 UHC declaration, which lacks specific references to technology transfer. Nevertheless, all references to technology transfer in the 2023 UHC political declaration are weakened by phrases like “voluntary,” “where possible,” and “on mutually agreed terms.” Given their framing, these commitments are nonbinding and narrowly focused on voluntary measures. States could have adopted binding commitments to mandate technology sharing and promote the sustainability of universal health coverage, but failed. Failing to acknowledge the need for mandatory technology transfer measures was yet another missed opportunity this year.
Conditionalities on publicly funded research
Governments fund significant portions of pharmaceutical research and development efforts. Estimates suggest that the United States invested tens of billions of dollars to develop, produce, and purchase mRNA vaccines. Moreover, 70 percent of tuberculosis research and development funding in 2021 came from public entities, with the United States National Institutes of Health (NIH) providing the largest single allocation at 354 million dollars. Public funding is considerable in other areas, like gene therapies. Governments could leverage these investments to promote the sustainability of universal health coverage programs. This can be sought by embedding global equitable access and technology transfer conditionalities on contracts with product developers. Public funders, however, often fail to contractually require their grantees to openly share knowledge and distribute their products equitably across the globe.
States are beginning to acknowledge that supporting the development of technologies without securing contractual safeguards that promote their equitable distribution is a policy failure. Although weak, States have made commitments to “promote” the transfer of technology and knowledge “where possible” in agreements that involve government funding for research and development. In line with these commitments, paragraph 74 of the 2023 UHC political declaration also reflects commitments to “promote” the transfer of technology and knowledge “where possible” in agreements that involve government funding for research and development.
While linking the need to secure contractual safeguards to political commitments about universal health coverage is important, the language in paragraph 74 is merely reflective of agreements adopted before. Phrases like “where possible” and “voluntary” in the 2023 UHC declaration indicate that these commitments are weak, nonbinding, and narrow. Failure to adopt binding and strong commitments requiring governments to seek contractual safeguards as a standard principle when public funding is involved was another missed opportunity at UNGA this year.
Decentralize manufacturing, research, and development
Sustaining universal health coverage requires decentralized global manufacturing capacity. Decentralizing manufacturing capacity through local and regional production can promote
equitable global availability of health products that are affordable and suitable for local populations. Local and regional manufacturing also promote resilient supply chains, which is critical for universal health coverage particularly during emergencies. Several initiatives are under way to strengthen local and regional capacities to manufacture health products, many of them motivated by the global inequitable distribution during the COVID-19 pandemic.
Consistent with those efforts, the 2023 UHC political declaration recognized “the need to support developing countries to build expertise and strengthen local and regional production of vaccines, medicines, diagnostics and other health technologies in order to facilitate equitable access.” One of the motivations for decentralized manufacturing acknowledged in the 2023 UHC political declaration is the fact that “the high prices of some health products and the inequitable access to such products impede progress towards achieving universal health coverage, particularly for developing countries.” Highlighting existing efforts to decentralize manufacturing capacity in the high-level political conversation about universal health coverage is an important contribution.
Yet, in line with other agreements, commitments around local and regional manufacturing could have been broader. States have previously acknowledged the need for comprehensive approaches to strengthening local capabilities. In the Seventy-fourth World Health Assembly, World Health Organization (WHO) Member States called for “a holistic approach in strengthening local production by considering, for example, promoting research and development.” Programs like the WHO mRNA Technology Transfer Hub have the potential to strengthen local manufacturing but also research and development of novel vaccines, treatments, diagnostics, and other health products. This year States missed the opportunity to adopt broader commitments, including the need to implement holistic approaches that includes promoting research and development locally and regionally to reduce dependence from developers in rich countries.
Transparency in pharmaceutical markets
Publicly available information across the pharmaceutical supply chain is currently inadequate or wholly absent. This includes lack of adequate information about clinical trials costs, government contracts with pharmaceutical product developers, prices paid by end buyers, volume of products sold, among several other critical pieces of information. Without this information it is unnecessarily more difficult to design, implement, and monitor policies that address gaps in the markets for pharmaceuticals. Consistent with this, WHO member states first recognized the need to improve transparency of markets for medicines, vaccines, and other health technologies in a resolution adopted by the World Health Assembly in 2019. Since then, States have adopted an increasing number of international commitments on improving pharmaceutical transparency.
Paragraph 50 of the 2019 UHC political declaration had commitments relating to increasing transparency of “prices of medicines, vaccines, medical devices, diagnostics, assistive products, cell- and gene-based therapies and other health technologies.” Paragraph 75 of the 2023 UHC political declaration reflects a similar commitment to increase transparency around “prices” of pharmaceutical products. Although recognizing the need to improve transparency in the market for pharmaceuticals continues to be important, the failure of the 2023 UHC political declaration to expand this commitment is yet another missed opportunity. Other areas where transparency is needed include the full government contracts with product developers and costs of clinical trials.